Plasma Glycated Hemoglobin A1c Could Predict 30-Day All-cause Mortality of Intensive Care Unit Patients with Hyperglycemia.

BACKGROUND: An increased serum glucose level is a common finding among patients admitted to hospital with acute illness, including the intensive care unit (ICU), even without a history of previous diabetes mellitus (DM). Glycated hemoglobin (HbA1c) is not only a diagnostic tool for DM but may also has prognostic value for diabetic and non-diabetic populations. OBJECTIVES: To assess the relationship between HbA1c level on admission and clinical outcome among patients admitted to the ICU due to cardiopulmonary disorders with hyperglycemia. METHODS: Patients consecutively admitted to the ICU due to cardiopulmonary disorders who presented with hyperglycemia at admission were evaluated during a 6-month period. HbA1c and serum glucose levels were tested on admission and during the first 24-48 hours of hospitalization. Patients were divided according to HbA1c and compared in term of demographics. We evaluated the effect of HbA1c levels at admission on the clinical outcomes. RESULTS: Of patients with cardiopulmonary disorders who presented with hyperglycemia at admission to the ICU, 73 had HbA1c levels ≥ 6%, 92 had HbA1c levels < 6%: 63/165 (38.2%) known as diabetic patients. The 30-day all-cause mortality was higher in the group with high HbA1c levels; 38/73 vs. 32/98 (P = 0.02). Increased length of stay in the ICU and Acute Physiology and Chronic Health Evaluation II (APACHE II) score were associated with HbA1c ≥ 6% (P < 0.022 and P < 0.026), respectively. CONCLUSIONS: HbA1c ≥ 6% has an important clinical prognostic value among diabetic and non-diabetic patients with cardiopulmonary disorders and hyperglycemia.

Spotted Fever Group Rickettsioses in Israel, 2010-2019.

In a multicenter, nationwide, retrospective study of patients hospitalized with spotted fever group rickettsiosis in Israel during 2010-2019, we identified 42 cases, of which 36 were autochthonous. The most prevalent species was the Rickettsia conorii Israeli tick typhus strain (n = 33, 79%); infection with this species necessitated intensive care for 52% of patients and was associated with a 30% fatality rate. A history of tick bite was rare, found for only 5% of patients; eschar was found in 12%; and leukocytosis was more common than leukopenia. Most (72%) patients resided along the Mediterranean shoreline. For 3 patients, a new Rickettsia variant was identified and had been acquired in eastern, mountainous parts of Israel. One patient had prolonged fever before admission and clinical signs resembling tickborne lymphadenopathy. Our findings suggest that a broad range of Rickettsia species cause spotted fever group rickettsiosis in Israel.

Consecutive Measures of CRP Correlate with Length of Hospital Stay in Patients with Community-Acquired Pneumonia.

BACKGROUND: Accurate diagnosis of community acquired pneumonia (CAP) is crucial to its proper management and to combating antibiotic resistance. Levels of C-reactive protein (CRP) have been shown to distinguish pneumonia from other pathological conditions and can be used to control the severity of infection during admission. OBJECTIVES: To investigate an association between consecutive measurements of CRP and the severity of CAP in hospitalized patients. METHODS: A total of 500 patients with CAP were admitted to the hospital. Traditional markers of inflammation including CRP, leukocyte count, body temperature, were measured on the first, second, and fifth days of hospitalization. Correlations between these measures and the length of the hospital stay were calculated. RESULTS: Mean levels of CRP, body temperature, and leukocyte count were significantly lower on the second day after hospital admission and even lower on the fifth day. A positive correlation of medium strength was found between the level of CRP on the second day of hospitalization and the length of hospital stay (P < 0.001, rs = 0.447), and a negative correlation was noted between the decrease in CRP level from the first to second day and the length of hospital stay. CONCLUSIONS: CRP levels correlated with body temperature and leukocyte count, traditional markers of inflammation. A greater decrease in CRP level between the first and second day of hospitalization was associated with shorter hospital stay and rapid improvement. These findings support the use of CRP as a marker for the severity and complication of CAP.

[SURVIVAL OF PATIENTS WITH WORSENING CHRONIC OBSTRUCTIVE PULMONARY DISEASE].

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD), a common disease worldwide, refers to two frequently coexisting lung diseases, chronic bronchitis and emphysema. Physiologically, COPD represents a disruption in ventilation and in the exchange of gases in the lungs. A sharp worsening obstructive pulmonary disease with respiratory acidosis leads to repeated hospitalizations and high mortality rates. OBJECTIVE: This study examined patients with COPD during hospitalization. Parameters included: the number of patients admitted for a defined period of time, the time of ventilation, the average length of hospitalization, the treatment modality, the mortality rate and the percentage of returning patients. METHODS: We chose 260 admissions with worsening chronic obstructive pulmonary disease during a six month period in internal medicine departments and the intensive care unit. We selected patients who met the criteria and collected demographic data, complete blood tests including blood gases and checking the ventilator during hospitalization. We checked the relationship between the indices for hospitalization, and the mechanical ventilation. RESULTS: A total of 255 admissions were enrolled in the study; 13 patients were excluded. Data was collected from 242 hospitalizations; 242 admissions included 71 patients hospitalized more than once. Patients' age ranged from 34 to 97 years with a median age of 66.6 years. During hospitalization, 194 patients (80%) were admitted to the internal medicine departments and 48 patients (19.8%) needed mechanical ventilation in intensive care. Most patients (60.7%) were hospitalized for 2 to 4 days, but 50% of the group of patients were hospitalized for almost one week. CONCLUSION: Although the results were almost identical to those found in the literature we found other factors related to the aggravation of the disease e.g. smoking, ischemic heart disease and malignancy, which are more common in this group of diseases.

Optimal time needed for withdrawal of mechanical ventilation in patients with chronic obstructive pulmonary disease.

BACKGROUND: Exacerbations of chronic obstructive pulmonary disease (COPD) are a major problem worldwide and are usually the main indication for mechanical ventilation (MV), especially in the intensive care unit (ICU). The rate of weaning failure is also high and prolonged MV leads to complications of intubation. The goal is to wean these patients as soon as possible. OBJECTIVE: To determine the optimal time necessary to start the weaning process. METHODS: In an attempt to determine the length of MV and stay in the ICU, we compared the length of MV, weaning, reintubations and discharge during a 10 month period. This study included 122 patients on MV due to severe exacerbation of COPD who were not suitable for non-invasive ventilation. For each patient serial arterial blood gases were measured at admission and during hospitalization. PeCO2 (mixed expired CO2) was tested using a Datex S/5 instrument at follow-up. RESULTS: The study population comprised all patients who required MV; of these 122, 108 were ventilated from 6 to 140 hours (mean 48 +/- 42), 9 needed more than 168 hours, and 5 died due to severe ventilation-associated pneumonia. No correlation was found between pH, PCO2 and length of MV; these findings did not contribute to evaluation of the patient's condition nor did they enable us to predict the length of treatment necessary. CONCLUSION: Most of the patients (93%) ventilated for acute respiratory failure due to COPD required MV for only 6-90 hours.

Usefulness of various inflammatory markers to differentiate pulmonary edema from pneumonia.

BACKGROUND: Community-acquired pneumonia requiring hospitalization is a severe illness with high mortality, especially if the appropriate treatment is delayed. Sometimes diagnosis is difficult due to an equivocal clinical picture or chest film, or to accompanying diseases that mask or simulate pneumonia. OBJECTIVES: To assess the usefulness of certain inflammatory markers in differentiating pulmonary edema from pneumonia throughout the hospital stay in patients admitted for pneumonia or pulmonary edema of non-infectious origin and to monitor the response to treatment. METHODS: The study group comprised 50 patients admitted for pneumonia, 50 admitted for pulmonary edema and 30 healthy individuals. Blood samples for determination of leukocyte count, erythrocyte sedimentation rate (ESR), fibrinogen, C-reactive protein (CRP), albumin, sCD14 and oxidized fibrinogen were drawn upon admission, at 48 and 72 hours after admission, and at discharge from the intensive care unit. RESULTS: The levels of sCD14 were similar in both patient groups but higher than control levels during the first 48 hours (P< 0.03). They decreased gradually with hospital stay. The concentration of oxidized fibrinogen was similar in both patient groups and significantly lower than that of the healthy control group throughout the hospitalization period. CONCLUSIONS: Oxidized fibrinogen and sCD14 are not reliable markers for the diagnosis of pneumonia, for its differential diagnosis from pulmonary edema, and for patient follow-up throughout hospitalization. The finding of elevated levels of oxidized fibrinogen in the group of healthy controls warrants further study to identify the factors responsible for altering fibrinogen oxidation. The other markers are more indicative.

[Fat embolism syndrome following injuries and limb fractures].

Fat embolism syndrome is a clinical entity characterized by varying degrees of cerebral dysfunction, pulmonary changes and petechial rash that usually develop within 24-48 hours in a small percentage of victims after trauma and Long bone fractures. Deterioration can occur within a few hours Leading to unconsciousness or acute respiratory insufficiency, similar to adult respiratory distress syndrome (ARDS). The pathophysiology is still not clearly understood and there are two theories--the mechanical and biochemical cascade of events. It seems that the most significant diagnostic sign is hypoxemia with relatively normaL values of PaCO2 leading to development of radiographic "snow-like appearance" of the Lungs, resulting from the typical interstitial lung edema. Treatment consists of early fracture fixation, volume replacement, respiratory support and analgesia carefully managed since some of the patients may develop acute respiratory distress. The role of steroids and other drugs is still under debate. The vast majority of patients may heal without any complications, while 5%-10% of the patients may develop some neurological complications manifesting as behavior disturbances. The aim of this review is to update the clinical and pathophysiological aspects of fat embolism syndrome and to describe the various aspects of prevention and treatment.

[Weaning of COPD patients from mechanical ventilation].

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD), a common disease worldwide, refers to two frequently coexisting lung diseases, chronic bronchitis and emphysema. Physiologically, COPD represents a disruption in ventilation and in the exchange of gases in the lungs. Laboratory tests indicate elevated CO2 level, gradual reduction of the levels of oxygen and pH in arterial blood and elevated PeCO2. It does not include other obstructive diseases such as asthma. OBJECTIVE: Patients with COPD represent a large portion of those artificially ventilated in an ICU. In an attempt to determine the length of ventilation and stay in ICU, we compared the length of ventilation, weaning, reintubation and discharge during a period of ten months. METHODS: This study included 73 patients on mechanical ventilation (MV) due to severe exacerbation of COPD that were not suitable for non-invasive ventilation. Each patient's arterial blood gases (ABG) were measured upon admission and PeCO2 was tested using a Datex S/5 instrument. RESULTS: All patients included in the study needed MV; 67 patients were ventilated from 5 to 161 hours (average 40 + 47), 6 patients need more than one week. Three of these patients died due to severe ventilated associated pneumonia. No correlation was found between pH, Pco2 and length of artificial respiration; these findings do not contribute to evaluation of the patient's condition nor do they enable us to predict the length of treatment necessary. CONCLUSION: Most of the patients (92%) ventilated for acute respiratory failure due to chronic obstructive pulmonary disease (COPD) needed MV for only between 40-47 hours.

Insulin therapy of hyperglycemia in intensive care.

BACKGROUND: Hyperglycemia is common among patients admitted to intensive care units, and carries the risk for complications and prolonged ICU stay. With intensive insulin control of blood glucose, morbidity and mortality can be reduced. OBJECTIVES: To determine whether intensive or conventional insulin control of blood glucose in hyperglycemic ICU patients correlated with the prognosis. METHODS: Following admission to the ICU, hyperglycemic patients were randomly assigned to a group treated intensively with insulin targeting glucose at 110-140 mg/dl, or to a conventional insulin therapy group, where glucose, upon exceeding 200 mg/dl, was controlled at 140-200 mg/dl. Rates of morbidity and mortality, hypoglycemic episodes, and insulin dosage were compared. RESULTS: In the 41 patients treated intensively with insulin the glucose level was 142 +/- 14 mg/dl, as compared to 174+/-20 mg/dl in the 48 patients on conventional insulin treatment. Both groups were similar in age, acute physiology and chronic health evaluation score. Morbidity was also similar, except for increased vascular damage in the conventional treatment group and slightly shorter ICU stay in the intensive therapy group. Both groups had similar in-ICU, in-hospital, and 28 day mortalities, and similar rates of hypoglycemic episodes. The daily dosage of insulin was significantly higher with the conventional treatment (P= 0.004). CONCLUSIONS: Intensive insulin treatment did not affect the mortality or morbidity rates in ICU patients. The increased insulin dosage of conventional insulin treatment was attributable to the group's higher prevalence of diabetes. Future studies should address this bias and determine the optimal glucose target.

[The effect of dead space fraction on weaning from mechanical ventilation in COPD patients].

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a common disease that tends to occur worldwide. Physiologically, COPD represents a disruption in ventilation and in the exchange of gases in the lungs. Laboratory tests indicate elevated CO2 level, gradual reduction of the levels of oxygen and pH in arterial blood, and a consequent rise in the Dead Space Fraction (DSF) of the lungs. OBJECTIVE: Patients with COPD represent a large portion of those artificially ventilated in the Intensive Care Unit (ICU). In an attempt to develop a prognostic tool for the length of treatment, we compared the proportion of DSF to the length of artificial respiration. METHODS: This study included 49 patients receiving ventilation due to exacerbation of COPD. Each patient's arterial blood gases (ABG) were measured upon admission. PECO2 was tested using a Datex S/5 instrument. Subsequently, DSF was calculated using the Bohr equation. Statistical data was analyzed using the SPSS-11 program. RESULTS: Patients included in the study were respirated from 5 to 161 hours (average 40 +/- 47). In addition to ABG measurements, PECO2 levels were measured and DSF calculated for each patient. DSF values varied from 0.22 to 0.74 (average 0.119 +/- 0.489). No correlation was found between DSF and length of artificial respiration. These findings do not contribute to the evaluation of the patient's condition nor do they enable us to predict the length of treatment necessary. CONCLUSION: Evaluation of Dead Space Fraction does not provide a factor in estimating the length of treatment for patients with acute respiratory failure due to Chronic Obstructive Pulmonary Disease (COPD).

Severe hypercalcemia as a presenting sign of systemic lupus erythematosus.

The association of hypercalcemia and systemic lupus erythematosus is quite uncommon, with only three cases having been reported in the literature. We present a case in which this association is highlighted and demonstrate the presumed mechanism of high calcium level and the usefulness of early diagnosis and aggressive treatment.

[Levels of fibrinogen compared to crp in plasma as new marker in diagnosis of pulmonary edema of non septic origin].

INTRODUCTION: Community-acquired pneumonia, that requires hospitalization, is a severe illness with high mortality rates, especially in cases of delay of appropriate treatment. At times, the correct diagnosis of the disease is difficult due to equivocal clinical picture or chest film, accompanying diseases that could mask or simulate the pneumonia. THE AIMS OF OUR STUDY WERE: 1. follow-up levels of fibrinogen throughout hospitalization in the group of patients admitted to the hospital due to pneumonia and pulmonary edema of non-infectious origin; 2. an estimation opportunity using them as possible new markers for diagnosis of pneumonia and for following response to treatment. METHODS: Three groups of patients were studied: a group of 15 patients admitted due to pneumonia, a group of 15 patients admitted due to pulmonary edema, and a control group 15 healthy subjects. The blood samples for white blood cells count, erythrocyte sedimentation rates, levels of fibrinogen, C-reactive protein, albumin, were taken for each patient on admission, 48 and 72 hours following admission and on discharge day. The received dates were compared using Student t-test. RESULTS: The levels of fibrinogen were higher on admission, in the patients with pneumonia, maximally after 48 and 72 hours (P<0.001) in comparison to the control group. In pulmonary edema the fibrinogen levels were also high but less than those with pneumonia (P=0.0044), with gradual declining throughout hospitalization period (P> 0.027 for both groups in discharge day). The comparison of fibrinogen levels between groups of patients with pneumonia and pulmonary edema reveal statistically significant results at time of admission, after 48 and 72 hours but not on discharge day. CONCLUSION: Fibrinogens can be used as reliable markers for primary diagnosing of pneumonia or differential diagnosis from pulmonary edema, on admission and until 72 hours but not for patient follow-up throughout hospitalization period. Additional studies are needed for discovering other new markers for patient follow-up throughout hospitalization period.

[Severe hypercapnia in asthmatic attack].

This is an unusual case, of an adult man who was hospitalized with a severe asthmatic attack and severe hypercapnia, refractory to intensive medical treatment, which responded to pressure mechanical ventilation. We advise to consider this mode of treatment in similar cases.

Impact of serum C-reactive protein measurements in the first 2 days on the 30-day mortality in hospitalized patients with severe community-acquired pneumonia: a cohort study.

INTRODUCTION: The purpose of the study is to evaluate the impact of daily consecutive measurements of C-reactive protein (CRP) in the initial 2 days of hospitalization on the 30-day all-cause mortality in patients with severe community-acquired pneumonia (CAP). METHODS: We used 4 different thresholds of fractional decrease (FD) in CRP at the second day of admission (CRP2) of 25%, 30%, 40%, and 60%. In addition, we studied the association of each of these thresholds with the 30-day all-cause mortality. RESULTS: The mean age was 64 ± 20; males, 59%. The 30-day mortality rate was 18% (20/111). The mean serum CRP levels at the first day of all study group and CRP2 were 203 ± 98 vs 146 ± 92 mg/L, respectively, P = .05. The mean FD in CRP2 levels among the survivors was 33 %, whereas among the nonsurvivors, was 7%, P < .001. Multiple regression analysis revealed that FD less than 25% in CRP2 was associated with 30-day all-cause mortality, odds ratio of 3.07 (95% confidence interval, 2.84-5.03), P = .002, compared with those with FD more than 25% in CRP2. CONCLUSIONS: Fractional decrease less than 25% in CRP levels at the second day was significantly associated with 30-day all-cause mortality in hospitalized patients with severe CAP.

Switching therapy to bedtime for uncontrolled hypertension with a nondipping pattern: a prospective randomized-controlled study.

OBJECTIVE: Uncontrolled hypertension is present in most patients treated with only a single morning dose or fixed dose drug combination; usually a third of them have a high prevalence of a nondipper blood pressure pattern, especially patients with chronic illness. In most cases, nondipping is related partly to the absence of 24-h therapeutic coverage of the single morning doses. We have investigated the usefulness of shifting therapy to evening instead of the morning. AIM: The aim of the study was to better control blood pressure and convert patients with a nondipping pattern to a dipper pattern without the need to increase the dose of their drugs or the addition of any other family of drugs. METHODS: Among 200 hypertensive patients, we investigated the impact of treatment time on the blood pressure pattern in 60 patients (33.3%) with uncontrolled hypertension with a nondipper pattern on the basis of clinic measurements who were studied by 24-h ambulatory monitoring during 2 and 4 months of follow-up; all of them received their treatment in the morning. This group of patients was divided randomly into two groups of 30 patients each; one group continued to receive the medication on awakening and the other took their medication at bedtime. Most of the treatment involved calcium channel blockers and other angiotensin-converting-enzyme inhibitors (ACEI), and 20 patients were taking one tablet of combined treatment (calcium blocker with ACEI). RESULTS: The percentage of patients with controlled ambulatory blood pressure was 0.86 among patients taking the drug at bedtime (P=0.005). Twenty-six patients with uncontrolled hypertension, receiving one drug or combined therapy at bedtime, showed a significant reduction in the 24-h mean systolic and diastolic blood pressure (6.2 and 2.6 mmHg, respectively; P<0.009). This reduction was more prominent during night-time (8.3 and 5.0 mmHg; P<0.001). In addition, all 26 patients showed normal blood pressure less than 140/90 during clinic measurement at daytime. Only four patients treated with monotherapy in the morning were unresponsive to the switching, and their blood pressure was controlled by the addition of a second drug at bedtime. The control group (who continued taking therapy in the morning) showed no reduction in blood pressure during night-time and remained with uncontrolled hypertension as they were at the beginning of the study. CONCLUSION: In patients with uncontrolled hypertension, switching of therapy to bedtime should be considered to improve control and to avoid the nondipper pattern before any attempt is made to increase the dose or add more drugs. We need other research studies with long time follow-up to verify the efficacy of switching therapy.

Hypophosphatemia as a prognostic value in acute exacerbation of COPD.

BACKGROUND: Phosphorus (P) is an essential element in all living cells, it is extremely important in the process of production of adenosine triphosphate, main element in the structure of nucleic acids. Low levels of phosphorus in blood is very rare, however, it may be caused by unbalance between components participating in phosphorus cycle and affect performances of several systems. A low level of phosphorus in the blood increases the exacerbation and the severity of chronic obstructive pulmonary disease (COPD) and requires prolonged ventilation process. AIM: This study aims to examine the prognostic effects of hypophosphatemia in COPD patients and evaluate the correlation between phosphorus levels and severity, recurrences of attacks, ventilation duration and successful of weaning process. METHODS: Two hundred and fifty-five patients who were admitted because of worsening in COPD, from October 2010-April 2011, were examined. A comparison was made between the group with normal blood phosphorus (2.5-4.5 mg%), group of patients with low phosphorus (2-2.5 mg%) and group with very low phosphorous values (<2.0 mg%). RESULTS: Ninety-five per cent of all admissions had normal blood phosphorus levels, 3.3% had low phosphorus levels, and only 1.7% of all admissions had very low phosphorus levels. 2.4% of patients had both low levels of phosphorus and potassium. All patients (100%) with very low phosphorus needed mechanical ventilation, compared to 62.5% of patients with low phosphorus and 16.9% of patients with normal phosphorus levels. In addition, 16 ventilated patients (33% of all ventilated patients) had low potassium values. SUMMARY: Low blood phosphorus levels contribute to an increase in: COPD flare-up, need for ventilation, duration of hospitalisation, days in intensive care units and finally increased rate of mortality. Accordingly, close monitoring and careful adjustment of disorders correlated to electrolyte such as phosphorus, are crucial and may improve prognosis and also increase the survival rate of patients with COPD.

Posterior mediastinal goiters: Report of two cases and literature review.

Intrathoracic goiters represent substantial enlargement and descent of cervical thyroid tissue into the thoracic cavity, usually in the anterior mediastinum. Rarely, they extend posteriorly, causing obstructive symptoms, sometimes with acute onset. Posterior mediastinal goiters should be differentiated from other mediastinal masses by appropriate work-up, while computed tomography is the most valuable technique. We report two cases of such symptomatic goiters. First reported case was atypically presented with aspiration pneumonia and second was successfully operated. Our overview aims to increase awareness of this rare clinical entity due to possible respiratory compromise. Reasonable surgical management is mandatory.

Red blood cell transfusions--are we narrowing the evidence-practice gap? An observational study in 5 Israeli intensive care units.

PURPOSE: The aim of the study was to document transfusion practices in a cross section of general intensive care units (ICUs) in Israel and to determine whether current guidelines are being applied. MATERIALS AND METHODS: This prospective study was performed in 5 general ICUs in Israel over a 3-month period. Red cell transfusion data collected on consecutive patients included the trigger, units transfused per transfusion event, and indications, categorized either to treat a specified condition for which transfusions may be beneficial (acute hemorrhage, acute myocardial ischemia, or severe sepsis) or to treat a low hemoglobin concentration. RESULTS: Of the 238 patients studied, 50% received at least one red blood cell transfusion. The main indication for transfusion (43.7%, or 162/368 U transfused) was to treat a low hemoglobin concentration, in the absence of one of the specified conditions. Total red cell use was 3.0 ± 2.9 U per admission, and patients received a mean of 1.2 ± 0.4 U per transfusion event. The transfusion trigger for the whole group was 7.9 ± 1.1 g/dL. This did not differ significantly between the indications apart from a significantly higher trigger for patients with acute myocardial ischemia (8.8 ± 0.9 g/dL). In addition, patients with a history of heart disease had a higher trigger irrespective of the primary indication for transfusion and received significantly more units per transfusion event. Patients receiving a transfusion had significantly longer ICU stay and hospital mortality. CONCLUSIONS: Our study showed that evidence-practice gaps continue to exist, and it appears that physician behavior is mainly driven by the absolute level of hemoglobin. Educational interventions focused on these factors are required to limit the widespread and often unnecessary use of this scarce and potentially harmful resource.

Pneumomediastinum as a presenting symptom of perforated sigmoid cancer: a case report.

We report a rare case of spontaneous pneumomediastinum due to perforation of sigmoid cancer in a patient suffering from Vogt-Koyanagi-Harada syndrome and temporal arteritis, two rare diseases. This patient, who generally receives corticosteroid and methotrexate therapy, was admitted to hospital with vague abdominal and left flank pain, urinary disorders and low grade fever one day prior to admission. Initial evaluation including X-ray and laboratory tests was normal. Several hours later a repeat chest X-ray showed pneumomediastinum. Chest and abdominal Computed Tomgraphy were performed because of worsening abdominal pain, and revealed a perforated sigma due to carcinoma.